Allied Health / ECEI
Shades of Grey: Allied Health Assistants
As the demand for allied health services grows, the supply of adequately trained allied health professionals (AHPs) will become problematic. Allied Health Assistants (AHAs) have not been as widely used in the disability service sector as they have in the health sector. Utilising AHAs to deliver therapy supports can assist with managing workforce issues, particularly where AHPs are in high demand. However, the delegation of supports to AHAs is not straightforward and, currently, there is no national framework to guide this work.
The NDIA does not require AHAs to have any formal qualifications; what they do require is that the AHA is supervised and covered by the AHP’s professional indemnity insurance (or the therapist’s employing provider).
The NDIA website defines Level 1 and Level 2 Therapy Assistants as follows:
Therapy Assistant (level 1): Allied health assistant working under the delegation of and direct supervision at all times of a therapist. The allied health assistant must be covered by the professional indemnity insurance of the supervising therapist (or the therapist’s employing provider).
Therapy Assistant (level 2): Allied health assistant working under the delegation and supervision of a therapist, where the therapist is satisfied that the allied health assistant is able to work independently without direct supervision at all times. The allied health assistant must be covered by the professional indemnity insurance of the supervising therapist (or the therapist’s employing provider).
Level 1 Therapy Assistants are rarely used apart from supporting participants in a group setting where the AHP is also present. This is because direct supervision by the AHP would require participants to fund both the AHP and the AHA, which would undermine any cost benefit rationale.
NB: Whilst the NDIA website link https://www.ndis.gov.au/providers/price-guides-and-pricing/pricing-review-therapy-services states that the allied health assistant must be covered by the professional indemnity insurance of the supervising therapist (or the therapists’ employing provider). The 20-21 price guide states that: Where a support is delivered by a therapy assistant, the therapy assistant must be covered by the professional indemnity insurance of the supervising therapist (or the therapist's or therapy assistant's employing provider).
Different state & territory AHA frameworks
In the 2019 Review of Therapy Pricing Arrangements, the NDIA points to the Victorian Supervision and Delegation Framework for AHAs in relation to qualifications, duties and supervision, but in fact, each state and territory’s framework identifies different levels of qualifications and competencies. If we just look at three jurisdictions—Victoria, NSW and Queensland, outlined below—we can see how much they differ.
The Victorian Framework identifies three AHA Grades:
AHA Grade 1 – No formal qualifications are required, and the AHA is required to perform work of a general nature under the direct supervision of an AHP.
AHA Grade 2 – Formal qualification consisting of at least a level III certificate from RTO or the equivalent is for the AHA to perform work of a general nature under the supervision of an AHP.
AHA Grade 3 – Formal qualification consisting of at least a level IV certificate from RTO or its equivalent is required for the AHA to perform work of a general nature under the supervision of an AHP.
While the Victorian framework suggests that Level 1 AHAs may work without any qualification, the NSW Allied Health Assistant Framework does not make the same distinction. It is unclear whether the qualifications of AHAs in the NDIS market must be in line with this framework (developed for health), however this framework could be considered indicative of the skills required to work in a comparable role.
Component 1 – Education, Skills and Competencies
A relevant qualification equips AHAs to undertake the scope of practice required for their position.
The level III certificate and level IV certificate in Allied Health Assistance informs the scope of practice for AHAs.
AHAs are to be encouraged to attain competence.
Similarly, the Queensland Allied Health Assistant Framework includes Component 2 – Education, Skills and Competencies
The Certificate IV in Allied Health Assistance has been identified as the qualification that best enables the full scope of practice for AHAs.
AHAs currently employed in the Queensland public health system are encouraged to participate in a recognition of prior learning (RPL) process as part of meeting the relevant qualification requirements.
AHAs should be encouraged to progress to attainment of the competencies and skill sets required for/or linked to the role.
Some roles may have mandatory qualifications and/or skill sets that are determined by the requirements of the position.
Indeed, the findings from the Therapy Assistant Benchmarking exercise identified that, despite the existence of national and state frameworks, there is currently no standardised definition of therapy assistants across Australia in terms of qualifications and activities.
Are the qualifications fit for purpose?
Adding to the complexity, the current Vocational, Education and Training (VET) courses are generally not well suited to helping students develop the skills required to deliver NDIS supports in the community. Most existing AHA VET courses offer health-focused training to prepare AHAs to work in clinical settings. They generally do not include the skills and knowledge that AHAs require to work independently in the community without access to an AHP on site. Therefore, even an AHA with a level III or level IV certificate is likely to require some significant orientation, supervision and on-the-job training. Some NDIS providers have engaged Allied Health undergraduate students to deliver AHA NDIS supports but, more commonly, we are hearing that AHPs are reluctant to use AHAs.
Delegation & code of conduct
AHPs are accountable for delegating allied health tasks to others and have a legal responsibility to determine that the AHA or disability support worker has the:
knowledge and skill level required to perform the delegated task; and
the appropriate level of supervision and feedback from the allied health professional in the performance of that delegated task.
State and territory AHA frameworks and professional codes provide guidelines for AHPs to make determinations about which tasks are suitable for delegation. The decision and accountability for delegation clearly lies with the AHP.
Including AHA funding in NDIS plans is problematic for AHPs as there is an assumption that supports are safe to be delegated and delivered by AHAs. We have heard about inconsistency in the way funding is included in plans; sometimes, the funds are designated as AHA support and, at other times, funds are included at the AHA rate. Regardless of how funding is included in plans, planners cannot make determinations about what supports can be delegated. This would be true even if they did have appropriate qualifications and an understanding of the supports required, as all the responsibility and liability lies with the AHP.
AHPs have reported facing pressure from the NDIA to delegate tasks that do not meet all the requirements for delegation; they are concerned that this could put them in breach of their professional code of conduct. This pressure also places some AHPs in a difficult position with families and support coordinators who do not fully understand the risk the AHP would be absorbing.
For example, the Physiotherapy Code of Conduct seeks to assist and support registered health practitioners to deliver effective regulated health services within an ethical framework. Concerns have been raised that the expectations of the Agency could put AHPs in breach of this code across a number of standards, including good care, risk management and teaching, supervising and assessing.
For example, section 4.3a states the requirement that reasonable steps must be taken to ensure that any person to whom a practitioner delegates, refers or hands over has the qualifications and/or experience and/or knowledge and/or skills to provide the care required.
NDIS providers are also bound by the NDIS Code of Conduct. This requires providers to provide supports and services in a safe and competent manner with care and skill and to promptly take steps to raise and act on concerns about matters that might have an impact on the quality and safety of supports provided to people with a disability. However the NDIS Commission does not regulate the NDIA, so AHPs are unable to use this resource to challenge a perceived high-risk funding decision.
Where to go from here?
It is easy to see why the NDIA and so many participants are enthusiastic about using AHAs. On the face of it, AHAs appear to provide value for money, allowing participants to access therapy supports at low cost, and they can certainly be a good option if their services can be delivered in a safe way to complement the work of AHPs.
AHPs have reported that they do see a place for AHAs in the NDIS, but clear guidelines and recommendations by the Agency are required to ensure safety and quality for participants. Further, given that AHPs are bound by a strict code of conduct and are responsible for the professional indemnity of AHAs, decisions about delegation must be the responsibility of AHPs. To support this decision-making, AHPs report that they need a framework that considers their professional registration requirements and any relevant state or territory requirements. The Independent Pricing Review recommends that a ‘clear framework should be developed to govern the use of therapy assistants under the NDIS, with detailed descriptions of required qualifications and eligible activities for each level’. An evidenced-based, well consulted framework would no doubt be welcomed by the allied health sector.